Antibiotic clinical decision support for pneumonia in the ED: A randomized trial

Derek J. Williams; Judith M. Martin; Hui Nian; Asli O. Weitkamp; Jason Slagle; Robert W. Turer; Srinivasan Suresh; Jakobi Johnson; Justine Stassun; Shari L. Just; Carrie Reale; Russ Beebe; Donald H. Arnold; James W. Antoon; Nancy S. Rixe; Laura F. Sartori; Robert E. Freundlich; Krow Ampofo; Andrew T. Pavia; Joshua C. Smith; Matthew B. Weinger; Yuwei Zhu; Carlos G. Grijalva

doi:10.1002/jhm.13101

Antibiotic clinical decision support for pneumonia in the ED: A randomized trial

Derek J. Williams, Judith M. Martin, Hui Nian, Asli O. Weitkamp, Jason Slagle, Robert W. Turer, Srinivasan Suresh, Jakobi Johnson, Justine Stassun, Shari L. Just, Carrie Reale, Russ Beebe, Donald H. Arnold, James W. Antoon, Nancy S. Rixe, Laura F. Sartori, Robert E. Freundlich, Krow Ampofo, Andrew T. Pavia, Joshua C. SmithMatthew B. Weinger, Yuwei Zhu, Carlos G. Grijalva

Research output: Contribution to journal › Article › peer-review

5 Scopus citations

Abstract

Background: Electronic health record-based clinical decision support (CDS) is a promising antibiotic stewardship strategy. Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED). Objective: To compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline-concordant antibiotic prescribing for pneumonia in the pediatric ED. Design: Pragmatic randomized clinical trial. Setting and Participants: Encounters for children (6 months-18 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States. Intervention: CDS or usual care was randomly assigned during 4-week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines. Main Outcome and Measures: The primary outcome was exclusive guideline-concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3- and 7-day revisits. Results: 1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline-concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre-specified stratified analyses, CDS was associated with guideline-concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; p =.024). There were no differences in safety outcomes. Conclusions: Effectiveness of ED-based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.

Original language	English (US)
Pages (from-to)	491-501
Number of pages	11
Journal	Journal of hospital medicine
Volume	18
Issue number	6
DOIs	https://doi.org/10.1002/jhm.13101
State	Published - Jun 2023

ASJC Scopus subject areas

Internal Medicine
Leadership and Management
Fundamentals and skills
Health Policy
Care Planning
Assessment and Diagnosis

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10.1002/jhm.13101

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Williams, D. J., Martin, J. M., Nian, H., Weitkamp, A. O., Slagle, J., Turer, R. W., Suresh, S., Johnson, J., Stassun, J., Just, S. L., Reale, C., Beebe, R., Arnold, D. H., Antoon, J. W., Rixe, N. S., Sartori, L. F., Freundlich, R. E., Ampofo, K., Pavia, A. T., ... Grijalva, C. G. (2023). Antibiotic clinical decision support for pneumonia in the ED: A randomized trial. Journal of hospital medicine, 18(6), 491-501. https://doi.org/10.1002/jhm.13101

Williams, DJ, Martin, JM, Nian, H, Weitkamp, AO, Slagle, J, Turer, RW, Suresh, S, Johnson, J, Stassun, J, Just, SL, Reale, C, Beebe, R, Arnold, DH, Antoon, JW, Rixe, NS, Sartori, LF, Freundlich, RE, Ampofo, K, Pavia, AT, Smith, JC, Weinger, MB, Zhu, Y & Grijalva, CG 2023, 'Antibiotic clinical decision support for pneumonia in the ED: A randomized trial', Journal of hospital medicine, vol. 18, no. 6, pp. 491-501. https://doi.org/10.1002/jhm.13101

@article{fbdf82d89336464480ad65f1258df098,

title = "Antibiotic clinical decision support for pneumonia in the ED: A randomized trial",

abstract = "Background: Electronic health record-based clinical decision support (CDS) is a promising antibiotic stewardship strategy. Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED). Objective: To compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline-concordant antibiotic prescribing for pneumonia in the pediatric ED. Design: Pragmatic randomized clinical trial. Setting and Participants: Encounters for children (6 months-18 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States. Intervention: CDS or usual care was randomly assigned during 4-week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines. Main Outcome and Measures: The primary outcome was exclusive guideline-concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3- and 7-day revisits. Results: 1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline-concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre-specified stratified analyses, CDS was associated with guideline-concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; p =.024). There were no differences in safety outcomes. Conclusions: Effectiveness of ED-based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.",

author = "Williams, {Derek J.} and Martin, {Judith M.} and Hui Nian and Weitkamp, {Asli O.} and Jason Slagle and Turer, {Robert W.} and Srinivasan Suresh and Jakobi Johnson and Justine Stassun and Just, {Shari L.} and Carrie Reale and Russ Beebe and Arnold, {Donald H.} and Antoon, {James W.} and Rixe, {Nancy S.} and Sartori, {Laura F.} and Freundlich, {Robert E.} and Krow Ampofo and Pavia, {Andrew T.} and Smith, {Joshua C.} and Weinger, {Matthew B.} and Yuwei Zhu and Grijalva, {Carlos G.}",

note = "Publisher Copyright: {\textcopyright} 2023 Society of Hospital Medicine.",

year = "2023",

month = jun,

doi = "10.1002/jhm.13101",

language = "English (US)",

volume = "18",

pages = "491--501",

journal = "Journal of hospital medicine",

issn = "1553-5592",

publisher = "John Wiley and Sons Inc.",

number = "6",

}

TY - JOUR

T1 - Antibiotic clinical decision support for pneumonia in the ED

T2 - A randomized trial

AU - Williams, Derek J.

AU - Martin, Judith M.

AU - Nian, Hui

AU - Weitkamp, Asli O.

AU - Slagle, Jason

AU - Turer, Robert W.

AU - Suresh, Srinivasan

AU - Johnson, Jakobi

AU - Stassun, Justine

AU - Just, Shari L.

AU - Reale, Carrie

AU - Beebe, Russ

AU - Arnold, Donald H.

AU - Antoon, James W.

AU - Rixe, Nancy S.

AU - Sartori, Laura F.

AU - Freundlich, Robert E.

AU - Ampofo, Krow

AU - Pavia, Andrew T.

AU - Smith, Joshua C.

AU - Weinger, Matthew B.

AU - Zhu, Yuwei

AU - Grijalva, Carlos G.

PY - 2023/6

Y1 - 2023/6

N2 - Background: Electronic health record-based clinical decision support (CDS) is a promising antibiotic stewardship strategy. Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED). Objective: To compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline-concordant antibiotic prescribing for pneumonia in the pediatric ED. Design: Pragmatic randomized clinical trial. Setting and Participants: Encounters for children (6 months-18 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States. Intervention: CDS or usual care was randomly assigned during 4-week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines. Main Outcome and Measures: The primary outcome was exclusive guideline-concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3- and 7-day revisits. Results: 1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline-concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre-specified stratified analyses, CDS was associated with guideline-concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; p =.024). There were no differences in safety outcomes. Conclusions: Effectiveness of ED-based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.

AB - Background: Electronic health record-based clinical decision support (CDS) is a promising antibiotic stewardship strategy. Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED). Objective: To compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline-concordant antibiotic prescribing for pneumonia in the pediatric ED. Design: Pragmatic randomized clinical trial. Setting and Participants: Encounters for children (6 months-18 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States. Intervention: CDS or usual care was randomly assigned during 4-week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines. Main Outcome and Measures: The primary outcome was exclusive guideline-concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3- and 7-day revisits. Results: 1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline-concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre-specified stratified analyses, CDS was associated with guideline-concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; p =.024). There were no differences in safety outcomes. Conclusions: Effectiveness of ED-based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.

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Antibiotic clinical decision support for pneumonia in the ED: A randomized trial

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